Updated edits for Medicare Plus Blue claims are coming in October 2021

As communicated in a March 2021 Record article, we’ll begin updating edits applied to Medicare Plus Blue℠ claims in October 2021. We’re enhancing our claim editing to promote correct coding and improve claim payment accuracy.

In the past, modifiers (including, but not limited to, modifiers 25, 59, 79 and 24) have been used to override bundling edits inappropriately. Due to the prevalence of incorrect modifier use, the Centers for Medicare & Medicaid Services:

• Adopted the Office of the Inspector General’s recommendations
• Implemented a prepayment review of modifiers using claim details and patient history for support of the modifier override

Registered nurses with coding credentials will utilize nationally sourced guidelines documented within the Current Procedural Terminology manual, the American Medical Association’s Coding with Modifiers manual, the CMS Correct Coding Initiatives manual, and the CMS claims processing manuals to review information on the claim and the patient’s claim history.

The additional review will ensure claims have been coded correctly for more complex situations where an overriding modifier has been appended. Providers should code claims to the level of specificity for the services rendered and appropriately append diagnosis codes and modifiers following the guidelines published by the AMA and CMS. The reported services should be supported in the patient’s medical record.

Modifier 25 guidelines

Append modifier 25 to evaluation and management services when they’re significant, separately identifiable, and performed by the same physician on the day of a procedure.

All E/M services provided on the same day as a procedure are part of the procedure, and Medicare only makes a separate payment if an exception applies. CPT guidelines define this significant and separate service as being above and beyond the usual preoperative and postoperative care associated with the procedure or service performed.

The E/M service must meet the key components (history, examination, medical decision making) of that service, including medical record documentation.

To use modifier 25 correctly, the chosen level of E/M service needs to be supported by adequate documentation for the appropriate level of service and referenced by a diagnosis code.

The CPT codes for procedures do include the evaluation services necessary before the performance of the procedure. (For example: The evaluation services could include assessing the site and condition of the problem area, explaining the procedure and obtaining informed consent.)

However, when significant and identifiable E/M services are performed, these services aren’t included in the descriptor for the procedure or service performed. (Examples of significant and identifiable E/M services could include medical decision-making and another key component.)

Appropriate usage

• Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and post-operative care associated with the procedure or service performed. 
• Use modifier 25 with the appropriate level of E/M service. 
• The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File. This global period could be 000, 010 or 090 days. 
• An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports modifier 25 and modifier 24 (unrelated E/M service during a post-operative period). 
• Use modifier 25 in the rare circumstance of an E/M service the day before a major surgery that isn’t the decision for surgery and represents a significant, separately identifiable service.

Inappropriate usage

• Submitted by a physician other than the physician performing the procedure
• Documentation shows the amount of work performed is consistent with that normally performed with the procedure

Modifiers 59, XE, XP, XS and XU guidelines

Modifiers 59, XE, XP, XS and XU should be used when the physician needs to indicate that a procedure or service was distinct or independent from other services performed on the same day.

Modifier 59 is used to identify procedures or services that aren’t normally reported together but are appropriate under certain circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.

CMS established the National Correct Coding Initiative program to ensure the correct coding of services. NCCI procedure to procedure edits prevent inappropriate payment of services that shouldn’t be reported together.

Each edit has a Column 1 and Column 2 HCPCS/CPT code. If a provider reports the two codes of an edit pair for the same patient on the same date of service, the Column 2 code is denied, and the Column 1 code is eligible for payment. When we update the claims editing, only select codes will allow modifier 59 to automatically bypass the NCCI code pair edits. Refer to the September 2021 Record article on modifier 59 for examples of appropriate usage.

Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary documentation. Also, continue to fax one appeal at a time to avoid processing delays.